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Advanced breast cancer tests

There are many different tests used to find out if breast cancer has spread. The tests vary depending on your symptoms and where the doctor suspects the cancer might have spread to. You may have a whole body CT scan. As the bones, liver and lungs are the most common places for secondary breast cancer, you are most likely to have tests for cancer spread to these parts of the body. These may include:

  • A bone scan
  • Blood tests to check how your liver is working, followed by an ultrasound or CT scan of the liver if the tests are abnormal
  • A chest X-ray to see if the cancer has spread to the lungs
  • A CT or MRI scan of your brain
  • A PET-CT scan to show where in the body the cells are more active than normal
  • A biopsy of areas of cancer in the lung or liver

The secondary cancer must be about the size of a pea before doctors can see it. Unfortunately there is no test that can pick up tiny secondary cancers.

Why don't I have these tests as part of routine follow up?

Most doctors only do scans and other tests if there is a reason to suspect that something is wrong. Having these tests regularly can't stop cancer from spreading. And finding out about cancer spread earlier often won't change how your doctor decides to treat you. One of the most important reasons for not doing tests too often is that many of them expose you to radiation, and your doctor will not want to do that if there is no need to.

 

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What the tests can find

Many different tests can be used to find out if breast cancer has spread. The tests vary depending on your symptoms and where the doctor suspects the cancer might have spread to. You may have a whole body CT scan. As the bones, liver and lungs are the most common places for secondary breast cancer, you are most likely to have tests for cancer spread to these parts of the body. You may have had some of the tests when diagnosing your primary breast cancer. You may have had a bone scan or a liver ultrasound at that point.

The tests help to spot secondary breast cancer but cancers don't often show up on scans until they are bigger than the size of a pea. Unfortunately there is no test that can pick up tiny secondary areas of cancer (micrometastases). Researchers are developing more accurate tests for spotting micrometastases.

In most cases it is the person themselves who suspects something is not right. But it is important to remember that the symptoms of secondary breast cancer are similar to many other common every day illnesses. So the symptoms may not be due to a cancer. If you are worried see your doctor and they can organise tests to find out.

 

Tests for secondary spread to the bones

X-rays can give a picture of the general condition of the bones. But X-rays may not show up small secondary tumours. A bone scan is better. It shows up tiny areas of affected bone.

Image showing an x-ray of bones

During a bone scan, you have a small amount of a mildly radioactive material injected into a vein (usually in the arm). The radioactive material travels around the body in the bloodstream. The bones take it up. More radioactivity is absorbed by abnormal bone than by normal bone. A special scanner is then used to show abnormal areas of bone. They are sometimes called hot spots.

If you are having a bone scan, it's important to know that hot spots do not necessarily mean cancer. They are just areas of damaged bone. Some other conditions, such as arthritis, also show up as hot spots. You could also have a CT scan or an MRI scan to check for cancer spread to the bones. These scans can sometimes show if the cancer has spread to the bones when the results of bone scans are not certain. Your doctor will look at the combined results of all your tests to see whether you have a secondary breast cancer.

There is information about having a bone scan.

When cancer spreads to the bones, it can make the bone cells release calcium into the bloodstream. Too much calcium in the blood can make you feel drowsy and sick. A blood test can measure the amount of calcium in your blood. If the calcium level is high (hypercalcaemia) you can have treatment to lower the level. For more information about treating hypercalcaemia, look in our section about coping physically with cancer.

 

Tests for secondary cancer spread to the liver

If you or your doctor think that your cancer may have spread to the liver, you may have a series of blood tests called liver function tests. You give one blood sample and the laboratory does a series of tests on that. The tests can show if your liver isn't working as well as it should. But it can't show whether any problem is due to secondary cancer or something else.

Your doctor may ask you to have a liver ultrasound scan because that can sometimes show secondary cancer in the liver even when the blood tests are normal. Or you may have a CT scan.

Image of CT liver scan

 

Tests for secondary cancer spread to the lungs

A chest X-ray or chest CT scan can show whether there is secondary breast cancer in the lungs. It also shows any build up of fluid around the lungs (a pleural effusion).

 

Tests for secondary cancer spread to the brain

A brain CT scan (also sometimes called a CAT scan) gives a clear picture of any secondary breast cancer cells in the brain. The scanner takes many cross section X-rays of your head. A computer creates images of the brain. To increase the detail, a technician may inject a dye into a vein, usually in your arm. You may feel hot all over for a few moments after the injection. We have information on having a CT scan.

An image of a head scan

Your doctor may suggest an MRI scan to examine the brain. Having this is similar to having a CT scan, but the scanner uses magnetism to build up a picture instead of X-rays. We have detailed information about having an MRI scan.

 

PET-CT scan

A PET-CT scan combines a CT scan and a PET scan into one scan. A CT scan takes pictures from all around your body and uses a computer to put them together. A PET scan uses a very small amount of an injected radioactive drug to show where in the body the cells are more active than normal. We have detailed information about PET scans.

The PET-CT scanner combines both of these types of information. This allows your doctor to see any changes in the activity of cells and know exactly where the changes are happening. You may have a PET-CT scan if other tests suggest that your breast cancer might have spread to another part of the body, but your doctors need to be sure.

 

Biopsy

Your doctor may take a biopsy of an area where the cancer has spread to the lung or liver. Then they can test the cancer cells to see if they have receptors for hormone therapies or biological therapies. 

You usually have a biopsy under a local anaesthetic in the outpatient department. The doctor may use an ultrasound scanner or a CT scan to guide the biopsy needle into the right place. The biopsy area may feel sore and uncomfortable for a couple of days afterwards. Your nurse will give you painkillers to take. The results of the test may take a couple of weeks to come through.

Hormone therapy receptors

Cells that have lots of oestrogen receptors are called oestrogen receptor positive. Cells that have lots of progesterone receptors are progesterone receptor positive. Breast cancers that are oestrogen receptor positive are more likely to respond to hormone therapies

Biological therapy receptors

Some breast cancers have many receptors for a protein called HER2. HER2 is made by a specific gene called the HER2/neu gene. HER2 is a receptor for a particular growth factor made in the body called human epidermal growth factor.

When human epidermal growth factor attaches itself to HER2 receptors on breast cancer cells it can stimulate the cells to divide and grow. If the breast cancer cells have a lot of HER2 receptors, the tumour is described as being HER2 positive. Biological therapies, such as trastuzumab (Herceptin), are more likely to work well on HER2 positive cancers.

 

Why tests aren't used in routine follow up

Most doctors don't do scans or other tests routinely after breast cancer treatment. They only do them if there is a reason to suspect that something is wrong. Having these tests regularly can't stop cancer from spreading. And finding out about cancer spread earlier often won't change how your doctor decides to treat you. One of the most important reasons for not doing tests too often is that many of them expose you to radiation. And your doctor won't want to keep exposing you to extra doses of radiation when there is no need.

Whether you have tests or not you may continue to worry that the cancer may come back, but it is very important to put this in context. Survival rates for breast cancer are improving. More than 85 out of every 100 women (85%) in England and Wales with breast cancer live for more than 5 years. Although no one will be able to give you a 100% guarantee that your cancer will not spread, for most women there is a very good chance that it has been cured.

There is no test that can pick up microscopic cancer spread. So a negative test doesn't necessarily mean that there is no cancer spread. People who worry a great deal about cancer spread won't necessarily have their minds put at rest by a scan, because there is always the chance that microscopic spread has been missed.

Many women find it very difficult to accept that scans and tests are not part of their routine check ups. You may wonder if they are not done because they cost too much. Although many scans are expensive, this is not the reason. 

You can talk these issues through with your doctor. If you are very keen to have routine tests, there may be a compromise you can come to about how often you have them. An occasional blood test or ultrasound scan might help to keep an eye on your health and also make you feel less anxious.

 

Waiting for results

You may worry while you wait for your tests, and then for the results to come through. You may think the cancer has come back or spread. But without the results of the tests you can't be sure.

You may feel torn between believing there is some other cause for your symptoms, which there may be, and thinking the worst. This uncertainty is often very hard. Many people with cancer say that not knowing is the worst thing about it. If your results confirm that you have secondary breast cancer, at least then you can prepare for your treatment.

If you would like more information about secondary breast cancer you can contact our cancer information nurses. They would be happy to help. If you would like someone to chat to, contact one of the cancer information organisations on our breast cancer organisations page.

If you want to find people to share experiences with online, you could use CancerChat, our online forum. Or go through My Wavelength. This is a free service that aims to put people with similar medical conditions in touch with each other.

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Updated: 24 July 2014